FORM
19.12 Petition for Adoption
IN THE COURT OF COMMON PLEAS OF
__________________ COUNTY, PENNSYLVANIA
IN RE: : No.
ADOPTION OF
PETITION FOR ADOPTION
TO THE HONORABLE, THE
JUDGES OF THE SAID COURT:
The petition of
__________________ and __________________, nee ________________,
under Section 2701 of the Adoption Act of 1980
as amended, respectfully represents:
1. Petitioners are adult individuals and
presently reside at __________________, and for the
past five years have
resided at the following addresses during the period specified:
2. Petitioners are (are not) husband and
wife, having been lawfully joined in marriage on the
____________ day of
__________________, 20______, in __________________. A true
and correct copy of
their marriage certificate is attached hereto and made part hereof, and
marked Exhibit ``A.''
3. If either petitioner was previously
married, explain how marriage was terminated. A certified
copy of divorce
decree is attached hereto and marked Exhibit ``B.''
4. The facts as to __________________, the
male petitioner, are:
a.Date and place of
birth:
b.Racial background
and religious affiliation:
c.Occupation:
d.Relationship to
adoptee by blood or marriage:
e.Names and ages of
children of male petitioner. State if natural or adopted:
5. The facts as to __________________, the
female petitioner, are:
a.Date and place of
birth:
b.Racial background
and religious affiliation:
c.Occupation:
d.Relationship to
adoptee by blood or marriage:
e.Names and ages of
children of female petitioner. State if natural or adopted:
6. The Report under Section 2530 relating to
preplacement investigation has been filed.
7. The Report of Intention to Adopt has been
filed on ____________, 20______.
(If not required,
state reason.)
8. The Report of the Intermediary was filed
on ____________, 20______. The name and
address of the
Intermediary is: (If not required, state reason.)
9. The Criminal
History Record and Application for Child Abuse History have been obtained and
are attached hereto
and marked Exhibit ``C.''
10. Facts as to the adoptee:
a.Date and place of
birth:
b.The Adoptee has
resided with the Petitioners since:
c.Religious
affiliation and race:
d.Birth certificate
is attached hereto, marked Exhibit ``D.''
e.No birth
certificate can be obtained at time of filing of this Petition because:
f.Relationship of
each Petitioner to adoptee is:
g.Describe fully and
state value of all property belonging to the adoptee:
11. Facts as to the natural parent(s) of
adoptee.
(Required where there
is no Report of Intermediary.)
A.Natural Mother
(1)Name:
(2)Birthdate and
birthplace:
(3)Residence or, if
unknown, last known address:
(4)Racial background:
(5)Religious
affiliation:
(6)Living or
deceased:
(7)Marital status at
time of birth of the child:
(8)Marital status
during one year prior to birth of the child:
B.Natural/Putative Father
(1)Name:
(2)Birthdate and
birthplace:
(3)Residence or, if
unknown, last address:
(4)Racial background:
(5)Religious
affiliation:
(6)Living or
deceased:
(7)Marital status at
time of birth of the child:
(8)Marital status
during one year prior to the birth of the child:
12. Identify proceedings in which any Decree
of Termination of Parental Rights with respect to
the adoptee was
entered:
13. No provision of any act regulating the
importation of dependent, delinquent or defective
children has been
violated with respect to the placing of the adoptee.
14. Petitioners desire to change the name of
the adoptee, __________________, to
__________________.
15. All consents required by Section 2711 of
the Act are attached to Exhibits or are not
required for the
reasons set forth below:
16. The consent of the natural parent(s) of
the adoptee is attached to this petition or was
attached to the
Intermediary's Report. Also attached is a copy of the natural parent(s) social
security card and
driver's license marked Exhibit ``E.'' If this has not been done, the reasons
are
set forth below:
17. All notice requirements under Section
2721 of the act have been satisfied, and, if not, the
reasons for same are
set forth below:
18. It is the desire of the Petitioner(s)
that the relationship of parent and child be established
between him/her/them
and the adoptee.
__________________
Petitioner
__________________
Petitioner
[Verification]